Department of General and Visceral Surgery, Cantonal Hospital of Lucerne, Spitalstrasse, CH-6000 Lucerne 16, Switzerland.
Department of General and Visceral Surgery, Cantonal Hospital of Lucerne, Spitalstrasse, CH-6000 Lucerne 16, Switzerland.
Injury. 2020 Apr;51(4):863-870. doi: 10.1016/j.injury.2020.02.089. Epub 2020 Feb 19.
To date, limited evidence exists regarding follow-up imaging during the non-operative management (NOM) of blunt splenic injury (BSI), especially concerning ultrasound as first-line imaging modality. The aim of this study was to investigate the incidence and time to failure of NOM as well as to evaluate the relevance of follow-up imaging.
All adult patients with BSI admitted to our level I trauma center, including two associated hospitals, between 01/01/2010 and 31/12/2017 were retrospectively analyzed. Demographic data, comorbidities, injury pattern, trauma mechanism, Injury Severity Score, splenic injury grade and free intra-abdominal fluid were reviewed. Additional analysis of indication, frequency, modality, results and consequences of follow-up imaging was performed. Risk factors for failure of NOM were evaluated using fisher's exact test.
A total of 122 patients with a mean age of 43.8 ± 20.7 years (16-84 years) met inclusion criteria. Twenty patients (16.4%) underwent immediate intervention. One-hundred-and-two patients (83.6%) were treated by NOM. Failure of NOM occurred in 4 patients (3.9%). Failure was significantly associated with active bleeding (3 of 4 [75%] failures vs. 8 of 98 [8.2%] non-failures, OR 33.75, 95% CI 3.1, 363.2, p = 0.004), and liver cirrhosis (2 of 4 [50%] failures vs. 0 of 98 [0%] non-failures, OR 197, 95% CI 7.4, 5265.1, p = 0.001). Eighty patients (78.4%) in the NOM-Group received follow-up imaging by ultrasound (US, n = 51) or computed tomography (CT, n = 29). In 57 cases, routine imaging examinations were conducted (43 US and 14 CT scans) without prior clinical deterioration. Fifty-fife (96.4%) of these imaging results revealed no new significant findings. Every failure of NOM was detected following clinical deterioration in the first 48 h.
To our knowledge this study includes the largest single centric patient cohort undergoing ultrasound as first-line follow-up imaging modality in the NOM setting of BSI in adult patients. The results indicate that a routine follow-up imaging, regardless of the modality, has limited therapeutic advantage. Indication for radiological follow-up should be based on clinical findings. If indicated, a CT scan should be used as preferred imaging modality.
迄今为止，有关钝性脾损伤（BSI）非手术治疗（NOM）期间的随访影像学检查的证据有限，尤其是关于超声作为一线影像学检查方法的证据。本研究旨在调查 NOM 的失败发生率和时间，并评估随访影像学的相关性。
回顾性分析 2010 年 1 月 1 日至 2017 年 12 月 31 日期间在我们的一级创伤中心（包括两家附属医院）收治的所有成人 BSI 患者。回顾性分析了患者的人口统计学数据、合并症、损伤模式、创伤机制、损伤严重程度评分、脾损伤分级和游离腹腔积液。对随访影像学检查的指征、频率、方式、结果和后果进行了额外分析。使用 Fisher 确切检验评估 NOM 失败的危险因素。
共有 122 名年龄在 43.8±20.7 岁（16-84 岁）的患者符合纳入标准。20 名患者（16.4%）接受了立即干预。102 名患者（83.6%）接受了 NOM 治疗。4 名患者（3.9%）发生了 NOM 失败。失败与活动性出血显著相关（4 名失败患者中有 3 名[75%] vs. 98 名非失败患者中有 8 名[8.2%]，OR 33.75，95%CI 3.1，363.2，p=0.004），与肝硬化显著相关（4 名失败患者中有 2 名[50%] vs. 98 名非失败患者中有 0 名[0%]，OR 197，95%CI 7.4，5265.1，p=0.001）。NOM 组中 80 名患者（78.4%）接受了超声（n=51）或计算机断层扫描（CT，n=29）的随访影像学检查。在 57 例中，常规影像学检查（43 例超声和 14 例 CT 扫描）未出现先前的临床恶化。这些影像学结果中有 55 例（96.4%）未发现新的显著发现。NOM 失败的每例均在首次 48 小时内出现临床恶化后被检测到。
据我们所知，这是一项包括最大的单一中心患者队列的研究，这些患者在成人 BSI 的 NOM 治疗中接受了超声作为一线随访影像学检查方法。结果表明，无论采用何种方式，常规随访影像学检查的治疗优势均有限。影像学检查的指征应基于临床发现。如果有指征，应首选 CT 扫描作为首选影像学检查方法。
